Acute Facial Nerve Palsy

Facial nerve: Supplies muscle of facial expression Five branches - splits in parotid gland - temporal, zygomatic, buccal, marginal mandibular, cervical Upper motor neurone paralysis: Usually due to stroke Sparring of forehead muscles If stroke is cause additional evidence usually found eg hemiparesis Lower motor neurone paralysis: Weakness of entire one half of face Facial nerve arises from its nucleus in the pons, emerges from pons to travel past cerebello-pontine angle (with V, VII and VIII) through petrous part of temporal bone to emerge from sylomastoid foramen, then into parotid gland, divides into branches In petrous bone facial nerve is accompanied by chorda tympani (taste fibres from anterior 2/3rds of one half of tongue) and gives off nerve to stapedius Lesions of facial nerve in temporal bone therefore produce loss of taste and hyperacusis (noise distorted, sounds loud) on affected side Causes LMN lesion: Bells palsyo Commonest cause of sudden onset isolated LMN facial nerve palsy o Believed to result from viral infection - produces swelling of facial nerve on temporal bone o May be associated hyperacusis and loss of taste anterior 2/3rds on one half of the tongue o Absence of involvement of other CNs is reassuring, suggests Bells o Treatment - most pts make full/spontaneous recovery over several months, small percentage will be left with permanent weakness, latest evidence suggests facial nerve palsy improves after treatment with combined Aciclovir and Prednisalone, advise use of artificial tears and an eye patch at night to prevent corneal drying Pontine tumour and vascular events - expect other signs (V and VIII involvement) Acoustic neuroma - usually evidence other CN involvement (V, VI, VIII nerves) at the cerebello-pontine angle (may present unilateral tinnitus) Ramsey-Hunt syndromeo Herpes zoster infection of geniculate ganglion o Clinical features of Bells palsy are present, plus herpetic vesicles present in the external auditory meatus and occasionally also on the soft palate o Refer to ENT specialist for Aciclovir and follow-up

Trauma Middle ear infections and cholesteatoma Sarcoidosis Parotid gland tumours, trauma and infection HIV

Grading system - House and Brackmann: Grade I - normal facial function Grade II - mild dysfunction o Slight weakness noted on inspection o Normal symmetry and tone at rest o Forehead motion moderate to good o Complete eye closure achieved with minimal effort o Slight mouth asymmetry noted Grade III - moderate dysfunction o Obvious but not disfiguring difference noted between both sides o Normal tone and symmetry at rest o Forehead movement slight to moderate o Complete eye closure achieved with effort o Slightly weak mouth movement noted with maximum effort Grade IV - moderately severe dysfunction o Obvious weakness and/or disfiguring asymmetry o Symmetry and tone normal at rest o No forehead motion noted o Eye closure incomplete o Asymmetric mouth noted with maximal effort Grade V - severe dysfunction o Only a barely perceptible motion noted o Asymmetry noted at rest o No forehead motion observed o Eye closure incomplete o Mouth movement only slight Grade VI - total paralysis o Gross asymmetry is noted o No movement noted Grades I-V incomplete, grade VI complete facial nerve palsy Grades I and II - considered good outcomes, grades III and IV - moderate dysfunction, grades V and VI - describe poor results Key points: Bells is diagnosis of exclusion Make sure eye is safe - tape or stitches against eversion Use corticosteroids if palsy complete or is painful

Retrovirals are worth a try